03/14/2025
Fill it out and send it to see how DOGE is monkeying around in your personal data.
U.S. Department of Government Efficiency 736 Jackson Place, NW
Washington, D.C. 20503
United States Digital Service 736 Jackson Place, NW Washington, D.C. 20503
RE: Privacy Act Access Request
Dear Privacy Officer or Coordinator:
March 11, 2025
In accordance with the Privacy Act, 5 U.S.C. § 552a(d)(1), I request copies of (1) all records about or pertaining to me in the possession or control of the U.S. Department of Government Efficiency (DOGE) or the United States Digital Service (USDS), and (2) all records about or pertaining to me contained within any system of records in the possession or control of DOGE and USDS, including any records or information about or pertaining to me that is contained in a copy, made or received by an employee or contractor of DOGE or USDS, including members of “DOGE Teams” or other DOGE-affiliated individuals.
Additionally, pursuant to 5 U.S.C. § 553a(c)(3), I request that you provide an accounting of the date, nature, and purpose of any disclosures that you, your agency, or your organization have made under 5 U.S.C. § 552a(b) providing access to a record about me to another person, organization, or agency, including within the Executive Office of the President.
I further request that you confirm that DOGE, USDS, and members of “DOGE Teams” or other DOGE-affiliated individuals will comply with the requirement of 5 U.S.C. § 553a(e)(7), that no agency may maintain records cross-referenced with information about how I have exercised rights guaranteed by the First Amendment unless expressly authorized by statute or unless pertinent to an authorized law enforcement activity.
To facilitate your response, I provide below my contact information and an itemized list of the records sought:
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Full name: _________________________________________
Mailing address: _________________________________________
_________________________________________
Preferred email address: ___________________________________
Date and place of birth: _________________________________________
Requested records pertaining to me containing my name, or the identifying number, symbol, or other identifying particular assigned to me:
◦ Education records
◦ Financial transaction records
◦ Medical histories
◦ Records relating to my eligibility for government benefits ◦ Criminal or employment histories
◦ Dissemination of my data to other entities: Pursuant to 5 U.S.C. § 552a(o)(2)(A)(ii), if any such records have been transmitted to a recipient agency as defined in 5 U.S.C. § 522a(a)(9), provide me a with copy of the written agreement between DOGE and/or USDS and the recipient agency or non-Federal agency specifying — (A) the purpose and legal authority for conducting the program; (B) the justification for the program and the anticipated results, including a specific estimate of any savings; (C) a description of the records that will be matched, including each data element that will be used, the approximate number of records that will be matched, and the projected starting and completion dates of the matching program; D) all other information required in such written agreement under 5 U.S.C. § 552a(o)(1)(A)-(K).
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Where possible, please provide responsive materials in an electronic format by mail to :
________________________________________________[INSERT email address].
Alternatively, please provide responsive materials in native format or in PDF format on a USB drive. Please send any responsive material sent in paper or USB drive form by mail to:
_______________________________________ [INSERT preferred mailing address].
If you contend that inspection of records must occur in person, provide me with accessible place(s) of inspection and the procedure to schedule it. Under 5 U.S.C. §552a(f)(5), you may not charge any fees for the search and review of these records. If paper copies are provided, please state the cost of duplication, and whether it exceeds the standard $0.05 per page.
If you deny this request, in whole or in part, please cite each specific exemption you feel justifies the refusal to release the information and notify me of appeal procedures available to me under the law. I expect a timely acknowledgement, response, and production of the requested records and information in accordance with the requirements of the Privacy Act.
Sincerely,
______________________________________________________
[WET SIGNATURE] IDENTITY VERIFICATION
In accordance with 28 U.S.C. § 1746, I, ____________________________[INSERT FULL NAME], declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above and requesting access to records about me. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more than $5,000, imprisonment for not more than eight years, or both, and that knowingly and willfully requesting or obtaining any record about any individual from an agency under false pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.
Dated: ________________ ____________________________________ [WET SIGNATURE]
